SUBTALAR JOINT RECONSTRUCTION By George E. Quill, Jr., M.D. The single axis subtalar joint is a hinge joining the talus and calcaneus that allows adaptation of the foot on uneven ground. This joint modifies the forces of ambulation imposed on the rest of the skeleton and influences the performance of the more distal foot articulations as well. When the structure and function of this joint are altered by trauma, instability, arthritis, infection, or tarsal coalition, subtalar reconstruction, usually in the form of arthrodesis, may prove to be a very successful procedure in treating the patient's resultant disability. The subtalar joint is, in this author's opinion, a very under appreciated joint. Even though it is estimated that up to 3 percent of the general population may have an asymptomatic talocalcaneal coalition present from a very young age and function very well, patients with a stiffened subtalar joint secondary to post-traumatic subtalar osteoarthrosis have very poor biomechanical function. Many patients presenting with "ankle " pain or who have pain from an ankle sprain that "just won't go away", may actually have subtalar pathology as an etiology for their discomfort. It is the astute orthopaedic surgeon who can recognize and successfully treat this pathology. Subtalar arthrodesis performed for the appropriate indications has proven to be one of this author's most gratifying, time-tested procedures in alleviating pain and improving function in patients so affected. Therefore, it is prudent that we understand the anatomic and functional aspects of the subtalar joint. The subtalar joint consists of three separate facets for articulation between the talus and calcaneus (Figure 1). A large uni-planar posterior facet is the most readily identified. The middle and anterior facets cradle the talar head. The direction of the subtalar axis is posterior, inferior, and lateral. Individual variations are numerous. In people with pes planus the axis of the subtalar joint is more horizontal than in those with more normal feet. A patient with flat feet often will have excessive wear on the medial border of his foot and shoe due to the greater supinating and pronating affect of the leg on the foot with this more 2 horizontal subtalar joint. On average, Manter has shown that the mean axis of motion of the subtalar joint is about 42 degrees with a range of 29 to 47 degrees inclination in the sagittal plane relative to the horizontal line and 16 degrees with a range from 8 to 24 degrees of medial deviation in the transverse plane relative to the long axis of the foot along the second ray. Functioning as a mitered hinge between the talus and calcaneus, the subtalar joint is, therefore, aligned at about 45 degrees to the horizontal and allows translation of transverse rotation occurring in the tibia into the foot. With subtalar arthrodesis, these rotational and other forces are transferred to adjacent nonfused joints in the foot and the ankle. Many authors have attempted to measure the residual motion in the foot and ankle after selective arthrodesis in the foot. Wilson has described the presence of tarsal hypermobility after subtalar fusion. On the other hand, Mann and Baumgardner reported a 50 percent loss of forefoot abduction and adduction after an isolated subtalar arthrodesis. This author has fairly frequently encountered patients after successful subtalar arthrodesis who will have a transient synovitis of the ankle during the first two to three months after cessation of postoperative casting. These patients are counseled preoperatively and postoperatively regarding the mechanics of their hindfoot and ankle and how these mechanics are affected by subtalar fusion. Most patients seem to understand that the ankle is also a hinge and that, having the subtalar joint fused, rapid walking with long strides on uneven surfaces may cause the ankle to sustain forces out of its usual plane of motion. The patients are told that the ankle normally functions as a hinge, and when they are so active on an uneven surface, they are asking it to function more as a universal joint. This excessive out-of-plane stress applied to the ankle is the etiology of temporary ankle synovitis after subtalar arthrodesis. Another clinical correlation that is pertinent here is the congenitally stiffened subtalar joint that occurs with clubfoot and certain forms of arthrogryposis. These patients often by adolescence have 3 developed a "ball and socket" type of ankle, because of the stresses transferred to the developing joint above the stiffened talocalcaneal articulation. Most authors proposing isolated arthrodesis of the subtalar joint as a therapeutic measure have concluded that, while degenerative radiographic changes can be appreciated at the ankle, talonavicular, and calcaneocuboid joints after isolated subtalar fusion, in most cases these radiographic changes of arthrosis do not correlate with clinical symptoms. Most of these patients are indeed asymptomatic at these often radiographically-abnormal joints on either side of the subtalar arthrodesis site. SUBTALAR ARTHRODESIS: INDICATIONS: By far the most commonly employed method of reconstructing the subtalar joint is by arthrodesis. This is considered by most authors a salvage technique. That is, one which is used to alleviate pain and correct deformity, but which is not necessarily reversible. This salvage technique involves sacrificing some of the preoperative "normal" joint structure, function, and motion in an attempt to eliminate pain. A successful subtalar arthrodesis, however, in the clinically appropriate position of 3 to 5 degrees of hindfoot valgus, can greatly improve the function of the patient with preoperative subtalar arthritis and/or deformity. Most of these patients who have undergone such a successful arthrodesis, when interviewed postoperatively, would gladly trade motion for stiffness in order to achieve pain relief. Many of my postoperative patients have remarked that their subtalar joint was so stiff preoperatively anyway, that they don't miss the painful small arc of preoperative motion that they traded for the pain free, surgically ankylosed joint they have obtained postoperatively. In this author's practice, the most common indication for subtalar arthrodesis is arthritis, usually of a post-traumatic etiology (Figure 2). These patients complain of daily pain in the hindfoot, usually associated with swelling. These patients have more difficulty walking on uneven surfaces than they do on 4 level ground due to loss of the normally accommodating subtalar motion. These patients will frequently "turn over" their ankle, even when walking on a small stone or pebble in their path. Only occasionally will they complain of locking. This symptom of locking is rare with subtalar arthritis and is usually more commonly attributed to ankle arthritis or loose bodies. Patients with significant post-traumatic osteoarthrosis of the subtalar joint will often have start-up pain upon arising from the seated position. A similar, related symptom is that of morning stiffness. These patients' symptoms may improve with a diagnostic - and sometimes therapeutic - Xylocaine or bupivacaine injection or with a trial of immobilization in a walking cast. For patients who receive such initial relief from these nonoperative measures, a trial of semi-rigid orthotics or a UCBL type of orthosis may occasionally obviate the need for surgery. Often these patients will improve in a high-top shoe or lace-up type of ankle and hindfoot brace. As reported by Myerson and Quill, in a series of 43 calcaneus fractures sustained in 42 patients undergoing late operative treatment for the sequelae of calcaneus fracture, very good improvement in function was obtained after subtalar arthrodesis in the appropriately indicated patients. An in situ subtalar arthrodesis was performed in 15 of these patients with post-traumatic osteoarthrosis limited to the subtalar joint after calcaneus fracture. The group of patients undergoing subtalar joint reconstruction by means of an in situ subtalar arthrodesis achieved an average improvement between the preoperative and postoperative foot rating scores of 54 percent. Thirteen of these fifteen patients returned to work in the same job they had held before sustaining their calcaneus fracture. One of the patients remained unemployed after subtalar reconstruction, and another remained in a sedentary occupation and did not return to full activities. These latter two patients ironically had excellent improvement between their preoperative and postoperative foot rating scores (from 5 to 87 and from 67 to 84 respectively). Figure 3 demonstrates a patient with post-traumatic osteoarthrosis limited to the subtalar joint after 5 calcaneus fracture who underwent successful reconstruction by means of an in situ subtalar arthrodesis with bone graft and internal fixation. Patients with primary osteoarthrosis will do just as well, if not better after subtalar arthrodesis than those with post-traumatic (secondary) osteoarthrosis of the subtalar joint. The former group of patients will usually have fewer soft tissue problems than the patients with post-traumatic osteoarthrosis. Wound problems, scar formation, significant preoperative deformity, and edema are also more common in the post- traumatic group of patients. Figure 4 (Vincent Peglino?) illustrates a 62-year-old gentleman with primary osteoarthrosis of subtalar joint who underwent a successful subtalar reconstruction by means of arthrodesis using bone graft